Rare Case of Pneumatosis Coli following Mycotic Aneurysm excision

Case Report | DOI: https://doi.org/10.31579/2690-1897/053

Rare Case of Pneumatosis Coli following Mycotic Aneurysm excision

  • Muhammad Peerbux 1*
  • Daniel Thompson 1
  • Sophie Cerutti 1
  • Yuwei Chen 1
  • Mr Phil Lu 1
  • Casey Fung 2
  • Casey Fung 2
  • Hansraj Bookun 2

*Corresponding Author: Muhammad Peerbux, St. Vincent’s Hospital Melbourne 41 Victoria Pde Fitzroy 3053 Victoria, Australia

Citation: Muhammad Peerbux., Daniel Thompson., Sophie Cerutti., Yuwei Chen., Mr Phil Lu., Casey Fung., Hansraj Bookun (2021) Rare Case of Pneumatosis Coli following Mycotic Aneurysm excision. J Surgical Case Reports and Images, 4(1); Doi: 10.31579/2690-1897/053

Copyright: © 2021 Muhammad Peerbux, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 26 November 2020 | Accepted: 16 December 2020 | Published: 05 January 2021

Keywords: pneumatosis coli; mycotic aneurysm

Abstract

Pneumatosis coli (PC) is a rare radiological phenomenon of the presence of gas in the wall of the large intestine. It carries a large burden of morbidity and mortality. All patients should have their underlying cause of PC investigated and have targeted therapy. In this novel case, a 68-year-old man developed PC following an aorto-bilateral common iliac artery mycotic aneurysm excision. Fortunately, he was asymptomatic and underwent close surveillance of this condition until near resolution. This case highlights the need for correlation of the patient’s symptoms and clinical features with appropriate aetiology and pathogenesis mechanism of the disease to guide management and optimise health outcomes.

Abbreviations

Pneumatosis Coli                                                 : (PC)

Computerised Tomography                                 : (CT)

Methicillin Sensitive Staphylococcus Aureus      :(MSSA)

Common Iliac Artery                                            :(CIA)

Computerised Tomography Abdomen Pelvis       :(CTAP)

Case Report: Rare case of Pneumatosis coli following Mycotic Aneurysm excision

Introduction

Pneumatosis coli (PC) is a radiological sign which is defined as the presence of gas in linear or cystic form in the submucosa or subserosal wall of the large intestine [1]. Although a rare occurrence, reported cases range from benign aetiology to life-threatening intraabdominal conditions [2]. A large proportion of patients are asymptomatic, however few commonly present with symptoms of diarrhoea, nausea, vomiting, haematochezia, weight loss, tenesmus, abdominal pain or distension and constipation [3]. Diagnosis is made through abdominal CT scan which includes features of circumferential (cystic) collections of air next to the lumen of the bowel wall, running parallel with the bowel wall or intraluminal air characteristically seen by linear collections with air-contrast or air-fluid levels [4]. Concerns are raised when intestinal ischaemia is noted on CT by decreased mural contrast-enhancement and the presence of portal venous gas [4]. The pathogenesis of PC is likely multifactorial and poorly understood in the literature. Causes range from mechanical tears along the luminal surface of the bowel mucosa to gas producing bacterial infection such as Clostridium perfringens infiltrating the bowel submucosa [3-5]. We highlight a case of PC occurring post-operatively in a man who underwent excision of a left aorto-iliac mycotic aneurysm secondary to septic arthritis of his left first metatarsophalangeal joint. This case highlights the importance for medical practitioners to identify the potential aetiology and pathogenicity pathways of PC and management options involved.

Case Report

A 68-year-old man who is an ex-smoker with a past history of hypertension and ischaemic heart disease underwent a washout and debridement of his left first metatarsophalangeal joint due to septic arthritis. Intraoperative specimens grew MSSA and he was commenced on intravenous flucloxacillin. Postoperatively, he developed intermittent fevers and back pain. CT-angiogram of the patient’s thoracic and lumbar spine revealed a 6.7cm left common iliac artery (CIA) aneurysm with focal uptake via a labelled white cell scan in the abdominal aortic aneurysmal wall suggestive of a mycotic aneurysm. The patient was taken emergently to theatre. A transperitoneal approach was performed via a midline laparotomy. Proximal control was at the infrarenal aorta and distal control was established by clamping both internal and external iliac arteries. A small focus of shallow ulceration was found on the duodenum which did not require repair after consultation with the general surgical team. Mycotic aneurysmal components involving the distal aorta, most of the left CIA and the proximal half of the right CIA were excised. An intraoperative decision was made to perform an in-situ reconstruction with a 16x8mmx8mm bifurcated Dacron graft. Histopathology revealed aortitis, without growth on culture and polymerase chain reaction testing.

The patient made an uneventful recovery and was discharged home with lifelong oral antibiotics. Routine surveillance CT-angiogram performed six weeks post-operatively demonstrated incidental new minor pneumatosis of the descending, transverse colon and part of the splenic flexure but no features of intestinal ischaemia (Figure 1).

Figure 1: Initial CTAP without contrast demonstrating PC (as shown by the yellow arrow) without evidence suggestive of intestinal ischaemia

Urgent outpatient consultations with the vascular and colorectal teams were organised. Fortunately, the patient was asymptomatic, with no reported abdominal pain or bowel changes. On examination, his abdomen was undistended, soft and non-tender. Digital rectal examination was normal. Interval surveillance CT-Abdomen Pelvis (CTAP) with contrast performed one week later (Figure 2) showed increased distribution of PC but this was much improved in another CTAP scan one month later (Figure 3).

Figure 2: CTAP with contrast 1 week later demonstrating increased distribution of PC (as shown by the yellow arrow)

 

Figure 3: CTAP with contrast 1 month later demonstrating resolving distribution of PC

As he was still asymptomatic, he was subsequently discharged from the colorectal clinic and followed up with his general practitioner.

Discussion

The two main challenges of PC are to avoid misdiagnosis as a malignancy or polyposis and to differentiate between the benign variety which requires conservative/medical management or the life-threatening form which requires emergent theatre [3].

The majority of cases of PC are idiopathic [2]. However, there is a wide variety of secondary causes related to gastrointestinal and non-gastrointestinal pathologies. The pathogenesis of PC can be classified as a mechanical, bacterial and biochemical. With mechanical causes, gas infiltrates into the bowel wall through breaks in the mucosa from the luminal surface or by tracking along the mesenteric blood vessels through the serosal surface [4]. This accounts for conditions such as necrotising enterocolitis, bowel ischaemia, inflammatory bowel disease and intestinal infections. The bacterial theory suggests that gas-producing bacteria infiltrate the submucosa through breaches in the mucosa the presence of gas within the bowel walls [2-4]. The biochemical trigger dictates that fermentation of carbohydrates produce large amounts of hydrogen gas resulting in increased intestinal luminal pressure, forcing the gas through the mucosa and becoming trapped in the submucosa [5].

All patients should have their underlying cause of PC investigated and have targeted therapy. Emergent exploratory laparotomy is indicated if they present with signs of abdominal peritonitis, have metabolic acidosis, acute kidney injury, leukocytosis greater than 12x109/L, lactate greater than 3.0 mmol/L or the presence of portal venous gas or bowel dilatation on CT [2-3, 6-9].

For patients who do not fit this criterion, management is guided by their symptoms and treatments include a combination of antibiotics, hyperbaric oxygenation and elemental diet [3]. If asymptomatic as in our case, no additional therapy is necessary and repeat abdominal imaging is performed every one-three months until resolution [6-9].

Conclusion
 Our predominant learning points are that PC is a rare but potentially fatal pathology that requires thorough evaluation. Correlation of the patient’s symptoms and clinical features with appropriate aetiology and pathogenesis mechanism of the disease is essential to guide management and optimise health outcomes. As outlined with this case, tactful surveillance may often be all that is required to allow resolution of this rare radiological finding.

Acknowledgements: Nil

Disclosure Statement: The authors have no relevant disclosures to make.

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad